Sleep Medicine Blog - Managing Insomnia, Restless Legs Syndrome, Obstructive Sleep Apnoea

Restless Legs Syndrome

2011-12-03T23:58:00.001+02:00

Sleeping problems

2011-12-03T23:56:00.001+02:00

Restless Legs Syndrome

2010-12-09T09:46:00.005+02:00

Restless legs syndrome (RLS) is the third most common reported sleep disorder, and one of the most common causes of severe insomnia. Including its mild form, this irritating disorder affects between 10 and 15 percent of the population. Although its classified separately as a movement disorder its important to note that all sleep related movement disorders are technically parasomnias.

Together they comprise the movement and behavioral disorders related to sleep. The way people describe their symptoms is often imprecise and can vary considerably, but the common denominator is an unpleasant sensation in the legs.

Sufferers may say they feel a "creepy, crawly" sensation in their legs when they trying to sleep or when they're just resting quietly. Or they describe extreme discomfort, pain, pulling, searing, boring, or deep itching sensations down the legs. Some patients have even described this sensation as 'electric ants' or bugs running up and down the legs.

The symptoms are typically relieved only by movement or stimulation of the legs. Doctors call this paresthesias -"abnormal sensations". For some people the feelings are a minor annoyance, and for others they're sheer torture. In all cases there's an urge to move the legs, getting the legs moving eases the symptoms temporarily.

WHO GETS RLS (Restless Legs Syndrome)

It can strike people of any age, RLS (Restless Legs Syndrome) is most commonly reported among people over the age of 40, and is classified as early onset if it strikes before the person is 45 years old. It's 1.5 to 2 times more common in women than in men. Many people who are later diagnosed with RLS ( Restless leg syndrome ) reporting having symptoms in childhood , and there's mounting evidence to suggest that its often misdiagnosed among children as attention deficit / hyperactivity disorder or " growing pains."

In more than half cases, primary RLS ( Restless legs syndrome ) runs in families. If you have an immediate family member with RLS ( Restless legs syndrome ), your risk is three to six times greater of developing the disorder.

Current exciting research shows that there may be a gene marker for RLS (Restless leg syndrome ) that explains this familial connection.

WHAT CAUSES RLS ( Resless legs syndrome ) ?

RLS ( Restless legs syndrome ) may be primary or secondary . Primary RLS ( Restless legs syndrome ) means that there is no underlying disorder causing it , whereas secondary RLS ( Restless legs syndrome) means that another condition ( medical or neurological ) or a medication is really at the root of it . In the latter case, treating the underlying condition or stopping and offending medication should resolve the RLS ( Resless leg syndrome ). Although the majority of cases of RLS ( Restless legs syndrome ) are primary ( with presumed problems with the brain's iron and dopamine systems), there are some known causes and associations with other conditions.

Iron deficiency and anemia are known to increase the risk of RLS (Restless legs syndrome ).
Several types of medications may bring on or aggravate RLS ( Restless legs syndrome ) , including many cold and allergy medications , antinausea medications, antidepressants ( except Wellbutrin, a adopmine-enhancing medication that may actually help ), antiseizure drugs, and antipsychotic drugs.
About 20-40 percent of those with chronic kidney failure on dialysis have RLS (Restess legs syndrome). The RLS (Restless leg syndrome ) symptoms disappear after a successful kidney transplant. The strong link between kidney disease and RLS ( Restless legs syndrome ) is still greatly under-recognised ,especially among kidney specialists.
Peripheral neuropathy , Parkason's disease, Lyme-disease myelitis,and diabetes mellitus have all been linked with RLS ( Restless legs syndrome )
Caffeine, tobacco, and nicotine can aggravate or trigger RLS ( Restless legs syndrome ) symptoms.

There is no evidence that RLS ( Restless legs syndrome ) is linked with any sort of underlying psychological problems. nor does it signal the onset of any other neurological disorder. However, because the distressing symptoms and resulting sleep deprivation of RLS ( Restless legs syndrome ) can be chronic, it can induce depressive and anxiety disorders.

PREGNANT WOMEN AND RLS ( Restless legs syndrome )

About 26 percent of pregnant women get RLS ( Restless legs syndrome ), and it gets worse in the second and third trimesters. Ten percent of them already had th disorder before they got pregnant,but it generally gets much worse during pregnancy. The remaining 16 percent didn't have the disorder before, and some worry that its going to harm the baby,or that it is a sign of something wrong. It isn't RLS ( Restless legs syndrome )in the mother does not pose any known risk for the baby. The problem that requires treatment is when the mother is losing significant amounts of sleep most nights because of the RLS ( Restless legs syndrome ). Dopamine medications,which are the most-recommended treatments for RLS ( Restless legs syn

Narcolepsy and Excessive Daytime Sleepiness

2010-11-30T23:15:00.001+02:00

Narcolepsy and Excessive Daytime Sleepiness
Narcolepsy is a serious, but relatively uncommon, disorder characterized by sudden and uncontrollable attacks of sleep. These attacks can be brief - lasting just 30 seconds - or longer, lasting as long as 30 minutes or more. Sometimes the attacks are accompanied by hallucinations and/or temporary paralysis. Narcolepsy can be quite debilitating, causing lack of muscle control and dream experiences occurring at inappropriate times.

Sufferers often unexpectedly fall asleep in the middle of important activities, including driving and while playing sports. This can be quite dangerous for themselves and others. In addition, they can fall asleep during conversations and at work, harming their personal and professional relationships.

Those with Narcolepsy often experience a temporary paralysis, which can be physically harmful if they fall down, and also very frightening when it occurs.

Research to date reveals that Narcolepsy appears to affect the part of the central nervous system that controls sleep and wakefulness and that it is not a psychological disorder. While there is no "cure" yet, recent advances in medicine, technology and pharmacology allow those with Narcolepsy to lead nearly normal lives. The finding that the Brain Protein called Orexin or Hypocretin is deficient in patients with Narcolepsy by leading researchers, including our own, is bringing hope of a cure. The doctors at the Sleep Medicine group of sleep centres are actively pursuing this research.

Diagnosing Narcolepsy needs to be done in a clinic that is familiar with sleep medicine. The patient's complete medical history is considered and the patient is given a thorough physical examination. Most often, patients are also given two tests, a polysomnogram and a multiple sleep latency test (MSLT) to confirm a suspected diagnosis and also to determine the extent of the Narcolepsy.

Excessive Daytime Sleepiness (EDS) is an essential part of the diagnosis of Narcolepsy but may have a variety of other causes including Obstructive Sleep Apnoea (OSA), Restless Legs Syndrome (RLS), Circadian Rhythm Disorder and the syndrome of Primary Hypersomnolence.

The symptom of EDS is important because it is associated with feeling drowsy and tired; having an overwhelming need to sleep during the day, being unable to stay awake in the daytime, even after getting a good night's sleep and falling asleep at times you need to be fully awake and alert.

It could mean ineffective work performance or dangerous levels of driving or other activities and, interference with a person's ability to concentrate or perform daily tasks or routines. Some people affected by EDS often feel frustration and anger about being misunderstood and being regarded as unintelligent or not interested in personal growth or learning. They often have low self-esteem and/or poor personal relationships as a result.

Narcolepsy

2010-11-30T23:15:00.000+02:00

Narcolepsy

Narcolepsy is characterized by the classic tetrad of excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Note that this tetrad is seen only rarely in children. The term "narcolepsy" is derived from Greek, "seized by somnolence." Gelineau was the first to delineate the syndrome in 1880.

Narcolepsy frequently is unrecognized, with a typical delay of 10 years between onset and diagnosis. Approximately 50% of adults with the disorder retrospectively report symptoms beginning in their teenage years. This disorder may lead to impairment of social and academic performance in otherwise intellectually normal children. The implications of the disease are often misunderstood by patients, parents, teachers, and health care professionals.

Narcolepsy is treatable. However, a multimodal approach is required for the most favourable outcome.

Narcolepsy is thought to result from genetic predisposition, abnormal neurotransmitter functioning and sensitivity, and abnormal immune modulation. Current data implicate certain human leukocyte antigen (HLA) subtypes and abnormalities in monoamine synaptic transmission, particularly in the pontine reticular activating system.

Understanding of the neurochemistry of narcolepsy stems primarily from research involving narcoleptic dogs (eg, special laboratory-bred Dobermans and Labradors). In these animal models, the disorder is transmitted in an autosomal recessive fashion with full penetrance and is characterized mainly by cataplexy.

Excessive daytime sleepiness (EDS) is the primary symptom of narcolepsy.

Sleepiness is a normal experience that cycles and invariably occurs after prolonged wakefulness. In healthy persons, mild sleepiness is apparent only during boring situations (eg, falling asleep while watching TV).
In patients with narcolepsy, severe EDS leads to involuntary somnolence during more active conditions such as eating and talking. Sleepiness in narcolepsy may be severe and constant, with paroxysms during which patients may fall asleep without warning (ie, sleep attacks).
Patients with narcolepsy tend to take short and refreshing naps (ie, REM type naps) during the day.
Several questionnaires evaluate sleepiness. The most commonly used is the 8-question Epworth Sleepiness Scale (1991).
Patients respond to each question on a scale from 0 (not at all likely to fall asleep) to 3 (very likely to fall asleep).
The resulting total score is between 0 and 24.
Although what score constitutes abnormal sleepiness is controversial, total scores above 10 generally warrant investigation.
Cataplexy (Latin, "to strike down with fear") is an abrupt attack of muscle weakness.

If severe and generalized, it may cause a fall.
More subtle forms exist with only partial loss of tone (eg, head nod).
The most characteristic feature of cataplexy is that it usually is triggered by emotions (usually laughter and anger).
Cataplexy is seen in about 70% of patients with narcolepsy, and its presence with EDS strongly suggests the diagnosis of narcolepsy. Specific historical questions concerning cataplexy are required.
Sleep paralysis is the inability to move upon falling asleep or awakening with consciousness intact.

It often is accompanied by hallucinations.
Sleep paralysis occurs during REM sleep in healthy subjects.
Sleep-related hallucinations may occur at sleep onset (ie, hypnagogic) or awakening (ie, hypnopompic) and are usually vivid (dreamlike) visual, auditory, or tactile in nature.

The classic picture of narcolepsy may be somewhat different in young children.

Children may deny EDS because of embarrassment.
Sometimes restlessness and motor overactivity may predominate.
Academic deterioration, inattentiveness, and emotional lability are common.
In one study of 51 prepubertal patients with narcolepsy, the following initial complaints were noted:
Children younger than 5 years presented with unexplained falls and "drop attacks," aggressive behavior, abrupt irritability, sleep terrors, and abrupt dropping of objects.
In children aged 5-10 years, the most common initial complaint was repetitive sleepiness, followed by difficulty with morning arousal associated with aggressive behavior and abrupt falls in school. These children often were misdiagnosed as having attention deficit hyperactivity disorder (ADHD), learning disability, or another neurologic disorder.
In children aged 10-12 years, poor academic performance was a common complaint. Other presenting symptoms included inappropriate low level of alertness, falling asleep in class, and inability to wake up in the morning.

Sleep Disorders

2010-11-30T23:14:00.000+02:00

OVERVIEW

Excessive daytime sleepiness, difficulty sleeping, and abnormal sleep behaviors are common problems that can have large impacts on a person's overall health, safety and quality of life. With accurate diagnosis, however, most sleep disorders can be effectively treated.

Sleep Disorders Treated by Dr Yacoob Omar Carrim - Sleep Medicine Specialist

Sleep-related breathing disorders

Obstructive sleep apnea (OSA) (including upper airway resistance syndrome)
- Pediatric sleep apnea

Central sleep apnea (CSA)

Snoring

Insomnia

Insomnia

Hypersomnias

Narcolepsy

Idiopathic hypersomnia

Circadian rhythm disorders

Delayed sleep phase syndrome

Advanced sleep phase syndrome

Jet lag

Shift work

Parasomnias

Arousal Disorders

Sleepwalking

Sleep terrors

REM behavior disorder (RBD)

Nightmares

Sleep-related eating disorder

Sleep-related movement disorders

Restless legs syndrome (RLS)

Periodic limb movement disorder (PLMD)

Bruxism

Leg cramps

Sleep starts

Sleep talking

Narcolepsy TREATMENT

2010-11-30T23:13:00.000+02:00

Narcolepsy
Overview

TREATMENT

Treatment plans for narcolepsy usually combine lifestyle modifications and medication. Plans need to be highly individualized and may require adjustment over time.

Lifestyle modifications
A patient's treatment team works with him or her to develop a daily plan to increase wakefulness. Elements of the plan may include:

Having a regular nighttime sleep schedule and adhering to it even on weekends
Taking naps at strategic times
Avoiding nicotine and alcohol
Getting regular exercise
Making changes at work or school to break up monotonous tasks. The Americans with Disabilities Act prohibits discrimination against workers with narcolepsy and requires employers to provide reasonable accommodation to qualified employees.
Avoiding driving if drowsy. If patients with narcolepsy must drive a long distance, they'll need to work with their treatment team to establish a medication schedule that ensures the greatest likelihood of wakefulness during the drive, and will need to stop for naps and exercise breaks whenever they feel drowsy. Patients should not drive if their sleepiness is not well controlled.

Medications
The best medication for a given patient depends on whether the patient experiences cataplexy, other medications being taking for other conditions, the patient's age, and response to particular drugs. Some medications often prescribed include:

Stimulants: Stimulate the central nervous system to help stay awake during the day. They include:
Modafinil (Provigil): Newer stimulant that isn't as addictive and doesn't produce the highs and lows often associated with older stimulants.

Methylphenidate (Ritalin)

Various amphetamines: Although effective, they may cause side effects, such as nervousness and heart palpitations.

Antidepressants: Suppress REM sleep to help alleviate the symptoms of cataplexy, hypnagogic (the boundary state between sleep and wakefulness) hallucinations, and sleep paralysis. Options include selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants.

Sodium oxybate (Xyrem): Controls cataplexy, sleep paralysis and hallucinations, helps improve nighttime sleep, and in high doses may also help control daytime sleepiness (though taken only at night). Associated with possible serious side effects, however, such as trouble breathing during sleep, sleepwalking and bed-wetting, and therefore strictly regulated by the Food and Drug Administration.

Fatigue Causes

2010-08-02T13:02:00.001+02:00

—Fatigue Cause No. 1: Not Enough Sleep

—Fatigue Cause No. 2: Sleep Apnea

—Fatigue Cause No. 3: Not Enough Fuel

—Fatigue Cause No. 4: Anemia

—Fatigue Cause No. 5: Depression

—Fatigue Cause No. 6: Hypothyroidism

—Fatigue Cause No. 7: Caffeine Overload

—Fatigue Cause No. 8: Hidden UTI

—Fatigue Cause No. 9: Diabetes

—Fatigue Cause No. 10: Dehydration

—Fatigue Cause No. 11: Heart Disease

—Fatigue Cause No. 12: Shift Work Sleep Disorder

—atigue Cause No. 13: Food Allergies

—Fatigue Cause No. 14: CFS and Fibromyalgia

Sleep Disorders and Fibromyalgia

2010-08-02T12:50:00.000+02:00

Fibromyalgia syndrome causes symptoms of extreme pain in the muscles throughout the body. Sometimes the pain associated with the illness can be so intense that sufferers cannot continue with their daily tasks. But fibromyalgia isn’t just associated with pain. Fibromyalgia and sleep disorders also go hand in hand. In fact, it is thought that up to 80% of people with fibromyalgia experience some type of disordered sleep. Often, these sleep disorders leave people feeling tired, drained, and physically incapable of dealing with the stresses associated with fibromyalgia.

Alpha EEG Anomaly
An alarming percentage of fibromyalgia sufferers have a sleep disorder called alpha EEG anomaly. This sleep disorder may actually be a cause of fibromyalgia because so many sufferers have it. Alpha EEG anomaly affects deep sleep, preventing sufferers from getting a good night’s rest.

Alpha EEG anomaly occurs when sudden bursts of brain activity occur during a time when the brain should be in deep sleep. These periods of intense activity are measured as alpha waves on an EEG monitor. People with alpha EEG anomaly do not have difficulty falling asleep, but once they reach deep sleep, their brains begin to act like they are awake. This leaves sufferers feeling tired and drained.

Sleep Apnea
80% of people with fibromyalgia suffer from sleep apnea, a disorder that causes momentary stoppages in breathing. Sleep apnea only occurs when a person is sleeping, but it can affect some people so badly that they actually cause themselves to wake up. Many people who suffer from sleep apnea don’t even know that they have it - usually it is a partner that notices the sufferer waking up.

In apnea, there are gaps in breathing that can last for a few seconds or even as long as a minute. These gaps are often caused by a collapse in the airway due to snoring or being overweight. This is referred to as obstructive sleep apnea. However, there is also a much less common form of sleep apnea that appears to be caused by a defect in the central nervous system.

Referred to as central sleep apnea, this type of apnea is caused by a miscommunication from the brain. For some reason, the brain "forgets" to tell the lungs to breathe. People suffering from this type of apnea usually remember waking up.

Sleep apnea symptoms can affect a person’s sleep patterns. Some people with severe sleep apnea actually wake themselves up hundreds of times a night, if only for a few seconds. This prevents the body from benefiting from any restorative sleep. Sleep apnea can leave fibromyalgia sufferers feeling increasingly fatigued and even more subject to pain.

Restless Leg Syndrome (RLS)
Many people with fibromyalgia suffer from restless leg syndrome symptoms. RLS causes unpleasant sensations in the lower limbs, so much so that the limbs have to be moved in order to reduce the pain. RLS occurs mostly at night, between the hours of 10:00 pm and 4:00 am, though it can also occur throughout the day in severe cases.

In a 2008 study, 64% of participants with FMS also had RLS.

RLS is exacerbated by long periods of rest, particularly nighttime sleeping, long car rides, or airplane travel. People with RLS describe crawling, itching, burning, or aching sensations beneath the skin in their legs. These sensations are so uncomfortable that they must move their legs, either by getting out of bed, or by exercising orstretching. Many find that if they do not move around, their legs will twitch involuntarily. Typically, RLS affects the calves and lower legs, though it can also affect the thighs, feet, and arms.

RLS causes major disturbances to sleep patterns. Because you are constantly being woken up or forced out of bed, many FM sufferers find that they just cannot get adequate rest. Many feel drained and sleepy during the day.

RLS is a neurological condition, but we don't yet know what causes it. Some cases may have a genetic cause, while others are believed to be related to:

Anemia
Pregnancy (especially in the last trimester)
Chronic diseases, including:
- Diabetes
- Parkinson's disease
- Kidney failure
- Peripheral neuropathy

Diagnostic criteria for RLS include:

A desire to move limbs, often linked to odd sensations
Symptoms that are present (or worse) when you rest; movement provides some temporary relief
Motor restlessness
Worsening symptoms at night

Symptoms of Restless Legs Syndrome and Fibromyalgia

Fibromyalgia and RLS share these symptoms:

Excessive daytime sleepiness
Problems with concentration

The primary symptom of RLS is odd sensations (parethesias) or unpleasant sensations (dysesthesias) in the legs and an uncontrollable urge to move to relieve these sensations. This phenomenon is not associated with FMS and requires different treatment.

Restless Legs Syndrome Treatment

RLS treatments can include medications and lifestyle changes.

For mild-to-moderate symptoms, your doctor may suggest you cut down or eliminate use of caffeine, alcohol and tobacco. If you have nutritional deficiencies, especially iron, folate or magnesium, your doctor may suggest supplements.

Other lifestyle management techniques include:

Maintaining a regular sleep schedule
Regular, moderate exercise
Avoiding excessive exercise
Hot baths
Leg massages
Applying heat or ice

These measures, however, don't generally provide complete symptom relief.

Your doctor may suggest medication to treat RLS. The more common types include:

Dopaminergics: (Examples are Requip, Mirapex) These drugs act like dopamine, which is a neurotransmitter that regulates muscle movement.
Benzodiazepines: (Examples are Valium, Xanax) These are central nervous system depressants, generally used as anti-anxiety medicines, that also suppress muscle contractions.
Opiates: (Examples are Darvon, Percodan) These pain killers also relax you and can suppress RLS in some people.
Anticonvulsants: (Examples are Neurontin, Tegretol) These are normally for preventing seizures but sometimes help relieve muscle contractions.

Some medications may make RLS symptoms worse, including antinausea, anticonvulsant and antipsychotic drugs and some cold or allergy medicines. If you're taking any of these, you may want to talk with your doctor about changing to drugs that are less likely to worsen your symptoms.

Restless Legs Syndrome Treatment vs. Fibromyalgia Treatment

RLS treatments don't generally conflict with FMS treatments, and in many cases, treatment may help both conditions. Many people with FMS find relief from benzodiazepines, opiates or anticonvulsants. (While they're widely used, benzodiazapines and opiates aren't part of official recommendations for FMS.) Also, many RLS lifestyle management techniques (regular sleep schedule, moderate exercise, hot baths) can be useful in managing FMS symptoms.

If you're taking or considering medications for both fibromyalgia and restless legs syndrome, be sure to talk with your doctor and pharmacist about any possible drug interactions.

Periodic Limb Movement Disorder (PLMD)
Periodic limb movement disorder often occurs alongside RLS. In fact, 80% of those fibromyalgia sufferers who have RLS also have PLMD. PLMD is very similar to RLS, however it only occurs during nighttime sleep. It can also become quite exacerbated and even violent, unlike RLS.

PLMD causes intermittent movement of a person’s limbs while they are in deep sleep. A person with PLMD may move their feet, knees, or thighs rhythmically without even realizing it. Most movements occur at intervals of between 5 and 60 seconds. For example, a person with PLMD might suddenly flex their knee, and then 60 seconds later, flex it again. These flexes tend to last for 10 seconds or more. The most common movements seen in this sleep disorder are flexes of the big toe, fanning of the toes, and flexion of the knees.

PLMD can be quite annoying when you are already suffering from widespread pain and other fibromyalgia symptoms. Sometimes people with PLMD can become quite violent, kicking and flailing while they are in bed. People with PLMD often report bouts of insomnia or daytime sleepiness, which can exacerbate their symptoms.

Bruxism
Bruxism (teeth grinding), frequently affects people with fibromyalgia. Bruxism is thought to be a part of a disease that is closely related to fibromyalgia, calledTemporomandibular Joint Disorder (TMJD). This disorder causes muscle pain in the face, neck, shoulders, and back, and often leads to grinding of the teeth. 75% of people with fibromyalgia also have TMJD.

Nocturnal bruxism occurs when you are sleeping. For some reason, sufferers begin to clench the muscles in their face causing their teeth to grind together. Many are unaware of this as they are sleeping, but in the morning they can be left feeling achy and sore in the jaw area. Bruxism can lead to a variety of dental problems, including loosened and broken teeth.

10 STEPS TO PEACEFUL BEDTIME By Claire Marketos

2010-07-14T12:27:00.000+02:00

10 STEPS TO PEACEFUL BEDTIME

By Claire Marketos

“Sweet dreams, my darling, sleep well, is every parent’s wish for their child. Yet, bedtime can sometimes be a nightmare with youngsters throwing tantrums. If sleep is vital for all of us, why are there so many children who don’t want to go to bed and struggle to fall asleep?

Physical, emotional, and environmental factors all play a part in how easily your child goes to bed and how well she sleeps. You know your child better than anyone else and so it is important to tune into her needs not only at bedtime but during the day as well. Here are some simple guidelines based on what children need to help you make bedtime a pleasure.

DAY TIME AND NIGHT-TIME

In order for your child to develop good sleeping habits, “You must follow the biological forces of sleep. Sleep should happen during night- time hours (the circadian rhythm) and children need to be awake for long enough to be sleepy (homeostatic force),” says Dr. Alison Bentley of The Wits Dial-a- Bed Research Laboratory.

“It is not fair to insist on a specific bedtime unless your child has been awake long enough for her to get sleepy, emphasizes Dr. Bentley, “You have to take daytime sleep into account.” If your child needs a nap, it should happen early in the afternoon. Toddlers, who fall asleep in the car after 3pm in the afternoon, will not be able to sleep easily at night.

ROUTINE

“The key to getting your child to sleep is consistency, consistency, consistency,” stresses Dr.Irshaad Ebrahim of The Constantia Sleep Centre in Cape Town. “Children of all ages respond to rules and routine, as this provides them with an element of predictability in their life and hence security, and they need this especially when they are tired,” explains Ebrahim. “Bedtime should happen in the same way, at the same time every night, as long as day time naps finish early enough,” Bentley points out.

Children can go to bed later on the weekend and during the holidays, once a bedtime routine has been established, and “both parents clearly and consistently explain that this is a variation from the routine,” stresses Ebrahim. The bedtime ritual you use may vary to the one outlined below. Nevertheless, it should get them to bed calmly and quickly, so that they can sleep for at least 8-12 hours a night.

When the child begins slowing down and is tired, it is time to start the bedtime routine. Don’t wait too long, otherwise she may get a second wind and then it becomes difficult to get her to sleep. Announce in a firm matter of fact tone, that it’s bedtime. “Time to say goodnight to everyone, brush your teeth, and go to the toilet.” This should take 5-10 minutes. You can make bedtime more fun by telling your child that her favourite teddy is waiting for them to cuddle, or by describing how snug her bed is going to be. A positive tone from you will reassure her that bedtime can be enjoyable.

For the next 10 minutes you can read a story, and your child can have a drink of warm milk. Give her a favourite soft toy or blanket. The bed and its surroundings should be free of any stimulating toys or pictures. Then, sit with your little one and gently stroke her if necessary to help her relax. Do not engage in conversation, say, “We’ll chat tomorrow.” If she keeps chatting say, “Go to sleep now, I’m going to pack things away in the kitchen.” “Make a slight noise,” Ebrahim advises, “to let your child know that you are still there.” Leaving a bathroom light on also makes children feel safe.

If your child comes out of her bedroom, calmly return her to bed. Be firm and reassuring but don’t resort to hitting or shouting, as “this can arouse the child and make them excitable and alert – the exact opposite of what you are trying to achieve,” explains Ebrahim. Sit with her until she is asleep. If you are implementing this routine for the first time, you may have to return your child to bed several times in the first week. Be tenacious, especially if you have to undo bad habits.

REASON

“Why do I have to go to bed now?”

Giving children an explanation of why they need to go to bed helps them to understand the importance of caring for themselves and being healthy. Tell your child: “You are tired. Your body needs to rest so you can grow big and strong, and so you can have lots of energy to play with your friends tomorrow.” Even very young children will listen to your explanation although they may not understand everything you are saying.

Acknowledge their feelings of not wanting to go to bed. “I know you don’t want to go to bed. I know you want to play with your toys. Tomorrow you will have play time again. It is bed time now.” Doing this initially, will relax and reassure your child, and you won’t have to say it every night.

PEACE AND QUIET

In order to sleep well, children need a peaceful environment with positive, calm parents who are in control. Stick to the bedtime routine, and support the parent, who is carrying it out. If you have ideas to make bedtime easier, discuss them with your partner once the children are sleeping. Be creative, and devise a plan together that makes bedtime a joy, rather than a chore.

Stop all stimulating activity including TV, an hour before bedtime, to help your kids calm down. They cannot sleep if they are not calm.

PHYSICAL NEEDS

In order to sleep well, children’s physical needs have to be met. A warm bath and a healthy, sit down dinner, (not in front of the TV), should take place in the hour before bedtime. Avoid sugary and salty foods, or foods which may have colourants and caffeine in them. After dinner, chat, read, or listen to classical music. Rough-and-tumble games with Mom or Dad should take place earlier in the evening.

On the other hand, physical activity during the day is imperative for good rest at night. If your children are sitting in front of the TV all afternoon, they will have more problems falling asleep than if they’ve had a fun day outdoors.

Always check for symptoms of illness which may be preventing your child from resting peacefully. If your child has persistent nightmares and anxiety at bedtime, consult your family doctor, or a child psychologist as there may be underlying issues of which you are not aware.

SECURITY AND SAFETY

You play a significant role in making your child feel safe and secure, which is important if she is to rest peacefully. Be aware of what you say in front of your children, especially when talking about violence. Keep arguments and fights with your partner private where the children can’t hear you. Kids usually blame themselves if there is conflict in the home and may spend many hours at night worrying about how to fix the problem, rather than sleeping.

Talk to your children about concerns they may have, such as the birth of a new sibling, the beginning of a new school year, disputes with friends and exams. Sometimes you may have to initiate chats and bring up topics, even if your child doesn’t tell you what’s bothering her. These conversations should always make the child feel secure. It is counterproductive to create more issues for them to worry about at bedtime.

Take your child’s fears of monsters hiding in her room seriously. Pretend to fight them off “or give them a torch to make them feel a little in control,” recommends Dr. Bentley.

Children should feel comfortable going to bed, so let them help you make their room and bed an inviting sanctuary.

YOUR FEELINGS IMPACT YOUR CHILD’S ABILITY TO SLEEP

“Children are extremely sensitive to their parent’s feelings. They will know from the way you hug them, look at them, and the tone of your voice, how you are feeling.” Ebrahim explains. “If they sense you are anxious, they may cry at bedtime for reassurance. If you allow them to stay up when they cry, they could interpret you actions as caring for them, or that they are not safe in bed. It depends slightly on the emotional situation in which this happens as to how various messages will be interpreted. Not all of the signals from your children relate to how your child is feeling, but how they think you might be feeling as well,”clarifies Ebrahim.

Give yourself enough time to de-stress before bedtime, and to sit with your child in their bedroom.

MOTIVATION

Having a goal to work towards gives children a sense of accomplishment when they achieve it and it also enhances their self esteem. Find positive ways to motivate your children. Having incentives such as a sticker chart to get them started may help. However, they should learn that sometimes we do things because it is the right thing to do and because it’s good for us. Never reward youngsters with food.

If a child throws a tantrum and resists having to go to bed, understand that she is trying to express her frustration and anger at having to make the change from playtime to bedtime. Acknowledge her feelings with the same exuberance she is expressing them- “You’re cross! You don’t want to go to bed. I understand. Tomorrow you can play again,” while calmly continuing with the bedtime routine.

Praise your children by telling them how proud you are of them when they are successful at bedtime.

LOVE AND COMPASSION

Children need to feel love and acceptance to sleep calmly. Show them patience and compassion when they are tired, and especially if they have been through a life changing experience, such as the birth of a sibling, divorce or death.

During these times, children may need more assurance and attention from you during the day, to help them feel secure at night. In severe cases they may also need play therapy from a professional child psychologist, especially if anxiety persists.

A child often regresses during difficult times, especially if there is a newborn in the parent’s room, and then it may be necessary for a mattress to be placed in the parent’s room for your older child to sleep on. Give her what she needs and then after several weeks, slowly help her to make the transition back to her own bedroom.

Attention from you is essential for peaceful sleep. If you are away from your child all day, she will want to attach to you from the moment she sees you, and therefore may act out at bedtime to be close to you.

Feelings of guilt should not prevent you from being firm and doing what is best for your child.

FOLLOW YOUR INSTINCTS

Most children who wake at night can be soothed back to sleep quickly. However, Dr Bentley explains “Children who have a very disruptive sleep disorder can wake up to seven times a night and demand either milk or rocking to go back to sleep. This is usually not due to any physical need but rather a behavioural disorder for which you may need professional help.” (See essential signs of seep disorders.)

ESSENTIAL SIGNS OF SLEEP DISORDERS IN CHILDREN:

1. Snoring and associated hyperactivity or sleepiness in the daytime

2. Interrupted breathing while asleep

3. Excessive limb movements in sleep

4. Sleepwalking

5. Sleep/night terrors (not the same as nightmares)

6. Inability to fall asleep, despite adequate parenting

If you feel your child may have a sleep disorder, talk to your general practitioner or paediatrician.

Chat to your partner and come up with a plan for the middle of the night you both agree on. If junior can climb into your bed without waking you or your partner, it will provide an excellent opportunity for you to all bond and cuddle, especially if you are separated during the day. If you are unable to sleep with junior in your bed, a mattress next to it may be an alternative, or follow the same routine you used at bedtime. Ensure your little one’s room is warm enough. You may want to use a sleeping bag if she kicks her blankets off. Letting her have one of your T-shirts that smells like you to cuddle with can provide solace.

If she has a nightmare or wakes up afraid during the night, gently reassure her that she is safe and that you are there for her. If the nightmares continue speak to your family doctor or a child psychologist. When you say goodnight to your child, remember to always tell her you love her and say: “With a butterfly kiss and a ladybug hug, sleep tight little one like a bug in a rug." A good night to you all.

Useful Contacts: Dr Yacoob Omar Carrim http://zasleep.blogspot.com

Obstructive Sleep Apnoea (OSA) - SNORING can KILL you

2010-07-08T14:18:00.000+02:00

Obstructive Sleep Apnoea (OSA)
Obstructive Sleep Apnoea (OSA) refers to any disorder in which there are breaks or pauses in a person's breathing during sleep. Most people who have OSA also snore, but not all snorers have OSA.. Diagnosing OSA needs to be done in a sleep centre and requires at least one Nocturnal Polysomnogram (PSG), which measures various physiological functions during the stages of sleep. A trained sleep technician monitors the patient continuously during the test. Then, the results are evaluated by a sleep disorder specialist, a diagnosis is made and a treatment plan is proposed.

The most effective means of treating OSA is by Continuous Positive Airway Pressure (CPAP). In this highly effective therapy, a mask is worn over the nose during sleep. Nasal CPAP provides a pressure splint to the upper airway, allowing the person to sleep and breathe normally. The airflow required must be determined through testing during sleep which is done during an overnight PSG.

OSA left untreated is associated with a much poorer long term outcome and increases the risk of cardiovascular, pulmonary and other diseases.

Disruption of sleep caused by frequent interruption of breathing, leading to excessive daytime sleepiness, irritability, memory lapses, inattention, personality changes, poor work performance, increased likelihood of driving and industrial accidents. Dangerously low levels of oxygen can lead to potential heart problems and other health disorders, including: depression, mood changes, memory loss, weight gain, impotency and headaches. Pressure changes in the throat can lead to an irregular heart beat. There is an increased risk of high blood pressure, premature heart disease and stroke.

The Sleep Medicine group of sleep centres provides a fully comprehensive diagnostic and treatment service for patients with OSA including Sleep Studies, Titration, Patient Education and Compliance Monitoring.

Seven-day sleep makeover Written by Hannah Ebelthite, Zest magazine

2010-07-08T14:17:00.000+02:00

We all know what makes for a good night's sleep - sticking to a routine, avoiding stimulants, learning to relax.

But a warm bath, a cup of camomile tea and a sniff of lavender often aren't enough to help us nod off. And unfortunately, next-day grogginess and irritability aren't the only consequences.

Bad quality sleep can suppress your immunity and make you more prone to illness. It may increase your risk of serious illness, too, such as diabetes and cardiovascular disease.

Plus, regularly sleeping fewer than seven hours a night may increase the risk of high blood pressure in women, says a study in the journal Hypertension. And research by the University Of Bristol links sleeplessness with weight gain - the less you slumber, the more appetite-stimulating hormone is released.

But even if you're not troubled by sleeplessness, you may still not be getting the quality of shut-eye you need.

So remedy that now, with our seven-day sleep makeover.

SUNDAY

Do this: keep a sleep diary

This will highlight your individual sleep patterns, says clinical hypnotherapist Glenn Harrold, author of Sleep Well Every Night (Orion, £9.99).

'Note the time you went to bed, to sleep, the total time slept, if you woke, what you did, any remedies you took, the last time you ate or drank, and your moods on going to bed and waking. After a week or so, you'll spot the factors that help or hinder your sleep.'

Did you know?

'Research shows that people in the UK get seven and a quarter hours' sleep per night on average,' says sleep expert Dr Neil Stanley of Norfolk And Norwich Hospital.

'But sleep need is like height or shoe size - it's different for everyone. So stop watching the clock and listen to your body instead. If you're alert and happy after six hours, that's fine; if you need nine, that's normal, too.'

Sleep clinic

If you're physically shattered but can't switch off, try spritzing Bach Rescue Night Spray (£8.05, from pharmacies) on your tongue - it's a variation on the classic Rescue Remedy formula, which quietens active minds.

Sunday-night sleeplessness is common, says Dr Stanley. 'It's a combination of not actually needing to go to sleep early, as you've probably had a lie-in and not been particularly active that day, and mental stress caused by thinking ahead to another week of work.'

Harrold suggests the following mindemptying technique: 'Breathe very slowly and deeply in through your nose and out through your mouth for about ten minutes.

'Allow your mind to go blank. Thoughts will still drift into your mind, but don't fight them. Just imagine a computer screen full of data that becomes blank by hitting a keypad. Imagine pressing that keypad, and you'll clear your mind.'

MONDAY

Do this: buy new curtains

'Like most animals, humans are biologically hard-wired to sleep at the onset of darkness,' says Harrold.

'Only when it's dark does your pineal gland release the hormone melatonin, which promotes deep sleep. Even an LED light on an alarm clock or chinks of light under the door are best avoided as you must aim to sleep in complete darkness,' says Harrold.

If you can't eliminate all light, buy an eye mask.

Did you know?

If you haven't exerted yourself during the day, physically and mentally, sleep may elude you at night.

'You lie down and your body says, "what's the point of this? I don't need it",’ says Dr Stanley.

'Research indicates that exercise during the day will help you sleep.' But don’t leave it too late. 'An evening gym session may mean you're too stimulated and hot to sleep well,' he says.

'If you hit the sack at 11pm, say, finish your workout by at least 8pm.'

Sleep clinic

If you fall asleep easily, but wake in the small hours and find it difficult to get back to sleep, then stop trying and do something different. 'Don't just lie there watching the clock,' says Dr Stanley.

'Sometimes just getting up to go to the loo is enough to break the cycle. Or maybe you need to switch on the light and read for ten minutes, or make a drink.'

Just try not to do anything stimulating, such as watching TV. 'The key is to accept you're awake and not to stress out - you'll soon wind down again.'

TUESDAY

Do this: try supplements

'B vitamins are essential for sleep and stress relief,' says nutritionist Alice Bradshaw. 'Take a good B complex formula, as the vitamins work best in synergy.'

And if stress and anxiety is the route to your insomnia - or vice versa - try the amino acid L-theanine. 'Studies show it promotes good quality sleep,' says Bradshaw, 'as it's involved in the production of neurotransmitters that have a calming effect akin to meditation.

'Research shows 5-HTP also improves sleep quality.' Try Solgar L-Theanine, £25.85, and 5-HTP, £9.95 (www.solgar-vitamins.co.uk).

Did you know?

Researchers at the University Of Geneva found that people who get a decent quota of sleep perform better in brain and memory function tests.

It's thought sleep helps your brain consolidate experiences and learning, and boosts memory, as connections between nerve cells are strengthened during slumber, which means sleep is vital before an exam or interview.

Sleep clinic

If you're one of the UK’s 15 million snorers, before you reach for the nasal strips and throat sprays, check what type you are.

The British Snoring & Sleep Apnoea Association has a test at www.britishsnoring.co.uk that identifies whether your snoring is caused by an allergy, nose-breathing, mouthbreathing, or is related to your tongue or soft palate. It then recommends appropriate solutions.

In all cases though, avoid alcohol, caffeine and smoking, and lose weight if you need to.

Also, see your doctor - snoring may indicate another, treatable problem, such as nasal polyps.

WEDNESDAY

Do this: de-electrify

A recent survey by the Sleep Council found that one in three of us makes phone calls or sends texts in bed, while one in five of us goes online, plays computer games or listens to their iPod. But it's definitely not a good idea, says Harrold.

'Studies show that electromagnetic fields (EMFs) from wi-fi, TVs, clock-radios and mobile phones affect sleep patterns in a negative way, stimulating your brain and body as you attempt to rest.'

He advises removing all electrical items from your bedroom with the exception of a daylight-simulating alarm clock (such as the Bodyclock at www.lumie.com).

Did you know?

A study at the University Of Zurich found that using a mobile phone for an hour before sleep increases brain activity, adversely affecting sleep.

'Keep your chats to earlier in the evening, and if you must have your mobile in the room with you, keep it at a distance - not on your bedside table next to your head. Or use a landline phone with a cord,' says Harrold.

Sleep clinic

If you sleep OK but wake up shattered, it may just be sleep inertia - the inability to come round fully after waking.

'For some people, the grogginess lasts minutes,' says Dr Stanley, 'but for others it's up to two hours. Natural daylight and using your body and brain will soon wake you up.'

What about that feeling when you've been dreaming all night and you wake up exhausted? 'The fact is you only remember dreams if you wake during them,' says Dr Stanley.

'So feeling that you have dreamed a lot actually means you've woken several times during the night.'

Dr Stanley also points out that dreams are very real. So if you dreamed you ran a triathlon or were being pursued, for example, your heart rate and breathing would have increased for real - another reason you may feel tired.

'Daytime tiredness may also indicate insomnia - the term refers to sleep quality as well as quantity,' says Dr Irshaad Ebrahim, who is the medical director of the London Sleep Centre.

'You may not always be aware if the sleep you're getting is poor quality. Look to your sleep environment, and ask your partner if you seem restless or noisy during the night.'

Identifying why you feel exhausted is the first step towards solving it.

THURSDAY

Do this: try hypnosis

'Hypnosis has a very similar effect on brainwave cycles as sleep,' says Harrold.

'The transition from full consciousness into a hypnotic trance will steadily slow your brainwaves and naturally guide you into a state that's ideal for sleep.' Harrold's book comes with self-hypnosis tips and a hypnosis CD to use before bed or if you wake during the night. Or to find a local practitioner, visit the British Society of Clinical Hypnosis at www.bsch.org.uk.

Did you know?

In a survey by the British Chiropractic Association, about 25 per cent of people blamed their bed for their back pain, and 40 per cent of back pain sufferers said that pain affected their sleep.

Memory foam neck pillows and mattresses such as Tempur (www.tempur.co.uk) relieve pressure on your joints and support the natural curvature of your spine.

In an independent survey, 86 per cent of Tempur customers with back pain said their mattress relieved the pain and gave them a better night's sleep.

Sleep clinic

If you have restless leg syndrome (RLS), you'll experience symptoms such as an itchy, 'crawling' feeling in your legs as bedtime approaches, and involuntary jerking of your legs during sleep that may be enough to disturb your sleep or that of your partner.

'We don't really know what causes this uncomfortable night-time twitching,' says Dr Stanley, 'but if it disrupts your sleep as well as your bedfellow's (who may sustain the odd bruise!), your doctor may be able to prescribe medication for it.'

'Caffeine consumption has been associated with RLS, so avoid it from late afternoon,' says Bradshaw.

Try soporific herbal teas, such as camomile and valerian, instead.

'Magnesium is needed for good muscle function, so supplements may ease symptoms,' she adds.

FRIDAY

Do this: eat right

Whether a nightcap or a mug of cocoa is more your style, neither is likely to improve your slumber, says nutrition consultant Ian Marber, founder of The Food Doctor.

'Alcohol may help you get to sleep, but it ultimately disturbs it,' he says.

'Herbal tea or water is better, but remember not to drink too close to bedtime - a full bladder will wake you up later.'

When it comes to food, he suggests similar abstinence.

'You hear about sleep-inducing foods such as turkey, lettuce and carbs, but really the best thing to go to bed on is an empty stomach. You don't need fuel for sleeping and an active digestive system delays deep sleep.

'Try to allow three to four hours between your evening meal and bed.'

Did you know?

In a Sleep Council survey, 41 per cent of us cited lack of sleep as the cause of morning grumpiness. And women feel it more than men - only 14 per cent of us never wake up in a bad mood, compared with 24 per cent of men.

Could that be because 28 per cent of us squeeze in housework between rising and going to work, compared with 5 per cent of men?

'Sleep problems statistically affect both sexes in roughly equal numbers,' says Dr Stanley.

'But in my experience women are more sensitive to and vocal about feeling sleep deprived.'

Sleep clinic

If your sleep is often disturbed by noisy neighbours or traffic, what can you do to lessen your exposure?

'It sounds obvious,' says Dr Stanley, 'but many people "train" themselves to sleep through such disruptions, when it might be more helpful to find ways to eliminate the disruptions.'

So talk to neighbours, fit secondary glazing, wear ear plugs, buy blackout blinds - whatever it takes.

SATURDAY

Do this: stick to your routine

'Get into the habit of going to bed and rising at the same time, even at weekends,' says Harrold.

'This will help regulate your sleep patterns so you’ll soon become sleepy and wake up naturally at the same time each day.'

Did you know?

A Greek study found that afternoon naps reduce stress levels and your risk of heart attack.

In fact, sleep researcher Dr Sara Mednick, author of Take A Nap! Change Your Life (Workman, £8.99), says a 20 to 90-minute nap before 4pm will increase mental performance and reduce your chance of weight gain by positively affecting your metabolism.

Sleep clinic

If you've tried it all and still can’t sleep, remember that hormones affect body temperature.

'This can result in disturbed sleep at certain times of your cycle, during pregnancy or the menopause. Adjust your environment to remain cool,' says Dr Ebrahim.

'Also, some medication, particularly antidepressants, may affect your sleep, so consult your doctor.'

If you think the cause is medical, ask your GP for help and don't be palmed off with sleeping pills.

'You can self-refer to a private sleep clinic,' says Dr Ebrahim. 'There, you'll see sleep experts and may spend nights at the clinic for observation.'

Last updated 15.01.2009

You can contact Dr Yacoob Omar Carrim on zasleep@gmail.com for a direct appointment.

Is CPAP a Therapy for Type 2 Diabetes?

2010-07-04T13:17:00.001+02:00

How Does Apnea Effect Diabetes?

A number of studies demonstrate that between 18 and 36% of Diabetic patients have Sleep Disordered Breathing (Snoring andSleep Apnea). Sleep Disordered Breathing results in intermittent hypoxia and sleep fragmentation, which is a cause of insulin resistance and excessive sympathetic nervous system activity.

Can CPAP Really Lower Glucose Levels?

Researchers from the Scripps Clinic in La Jolla, California studied a group of twenty DM patients recently diagnosed with Sleep Apnea. They continually measured BG levels with and without CPAP therapy in a sleep laboratory. The use of CPAP led to an average BG drop from 122mg/dL to 102.9mg/dL (p=0.03).

The findings show that successful CPAP therapy reduces hyperglycemia and stabilizes Blood Glucose during sleep. As a measure of this stability, the median Standard Deviation of sleeping BG markedly decreased from 20 to 13 (p=0.005) after CPAP.

A Call to Screen All Diabetics

As the authors of the study indicate, variability of BG levels is an independent risk factor for mortality and blindness in DM. Much can be gained with effective therapy for Snoring and Sleep Apnea.

CPAP is the most common therapy for SDB. It involves wearing a nasal mask during sleep which is attached by a long flexible hose to a PAP machine. The researchers suggest that physicians screen all DM patients for SDB, and treat SDB as a means of DM management as well as a strategy for disease prevention.

1. Dawson, A. et al. (2008). CPAP Therapy of Obstructive Sleep Apnea in Type 2 Diabetics Improves Glycemic Control During Sleep. Journal of Clinical Sleep Medicine, Vol. 4(6); 538-542.

voorblad Rapport: As die slaap nie wil kom nie 2010-07-03 12:43

2010-07-03T19:10:00.000+02:00

Insomnia - what is Insomnia and why is Insomnia important - what should we do about Insomnia

2010-07-03T19:05:00.000+02:00

Insomnia - this remains and justifiably so - one of the top reasons persons seek medical help. This problem is at the best of times resistant to remedies.

Insomnia refers to repeatedly difficulty in falling asleep or staying asleep, waking up too early, and or feeling unrefreshed the following day. If you have had difficulty falling asleep or had woken repeatedly at night but could function normally the next day, indicates that you have had sufficient appropriate sleep.

You do not have to sleep for eight hours or fit a social norm of sleep. You have to sleep the amount of time that is just right for you. All of us are different.

Some of us believe that we can abuse our sleep patterns by working all day and night - with a minimum of sleep and not get enough sleep. These people will soon realise that sleep is rigid and is madatory for survival. The birds, insects, animals, fish and all that is created needs to sleep - yes this includes all of us - inclusive of man and beast. Dolphins are fortunate to sleep with one brain hemisphere at a time - the other half of the brain remains awake to keep swimming.

The only being that does not have to sleep is God himself - "slumber does not seize him nor sleep" and "there is none like unto him." For us simple mortals we will have severe problems with every system of our bodies and mind if we deprive ourselves of sleep.

There are those that are short sleepers and require less sleep than average - the function perfectly well on 5 to 6 hours of sleep. These short sleepers are few and far between. For the average Joe we have to sleep on average 8,15 hours - a SA high school metric student requires 9 hours sleep!

Epidemiology and importance: Insomnia is known to affect 58% of western adults.

People that do not get sufficient appropriate sleep run the risk of having impaired cognition, memory, attention, and ability to plan , execute and follow up. They usually appear more irritable, more aggressive, and develop an underlying anxiety (more than depression). They perform poorly in their daily tasks - in whatever they choose to do. They have more motor vehicle accidents than average. Some suggest they have the same number of accidents as alcoholic drivers - I hope the authorities are reading this.

Definition of Insomnia
Insomnia is defined by time - there are 3 basic types:

Transient: Insomnia that lasts for less than a few weeks
Intermittent: Recurring transient insomnia
Chronic Insomnia: Insomnia that occurs for most nights for more than one month

Insomnia may be classified according to when it causes trouble: Recalling the definition of insomnia we may divide sleep into sleep onset insomnia, sleep maintenance insomnia and early morning awakening.

sleep onset insomnia, occurs when a person has trouble falling asleep in the first place
sleep maintenance insomnia, when a person wakes up at night and cant go back to sleep and
early morning awakening - waking up too early in the morning.

One may also get a combination of the above - mixed insomnias.

The time that it takes for the average South African to fall asleep differs - on average it takes people 7 minutes to fall asleep but you may require 20 to 30 minutes to fall asleep. The key question is are you able to function the next day, do you feel restored after sleep.

If you dont feel restored or you cant stand your inability to fall asleep or maintain sleep then its time to seek help from a Sleep Medicine Specialist.

How would I recognise an Insomniac?
Apart from those with underlying medical and psychiatric problems that need a sufficient appropriate diagnosis by their medical service provider there is a spectrum of Insomniacs -
The first are those that do all the right things to get ready for sleep and feel ready for sleep but just cant fall asleep.

The next are those that have no trouble falling asleep but are parting or working all night - burning the candle on both ends thinking that sleep is for the dead - they are of the mistaken belief that sleep is like a soccer ball that can be kicked about without any implication on their long term health.

There are also those that are being kept awake by the environment - the husband snoring, the wife with the restless moving legs, the sleep talking and sleep walking bed partners, a child with night terrors. We must never forget the nursing mothers that sacrifice their sleep for the suckling babes in the middle of the night (Breast remains best).

So who gets insomnia?
Anyone can get insomnia but these are the groups that have the highest risk of getting insomnia:

Elderly persons - the older you are, the more likely you are to have insomnia. One third of persons greater than 65 have insomnia.
Worriers: Those that are prone to anxiety are more likely to have insomnia.
Women have a slightly higher incidence of insomnia
Psychiatric disorders: those that have psychiatric disease such as anxiety, depression really do need the assistance of a registered psychiatrist.
Physical disorders: Pain, heart disease (cardiac disease)
Alcohol abuse and drug abuse: Alcohol induces sleep but does not allow you to have the deep stage 3 and 4 slow wave sleep required to restore the body or the REM sleep required to file the information for the day.
Certain Jobs - the more repetitive jobs that required less mental engagement had more difficulty falling asleep - as if the brain protests compelling you to use it before it will allow you to rest. If you dont use your brain - it will not allow you to sleep.

Insomnia may be caused by changes in the environment, physical medical causes, and psychological causes.

The changes in the environment may be a change in routine, and sudden change in the weather or poor sleeping conditions.
My patients that have illness be it the flu or a serious heart, lung, kidney or stomach problem have worsening insomnia. Those that suffer the most are those with chronic pain conditions. Medication given by homoeopaths and doctors may cause change in the wake sleep cycle.
Changes in hormones - menstruation, pregnancy, menopause and hot flushes really cause havoc in my female patients sleep.
Caffeine and smoking: Tea, coffee, coke and dark chocolate are stimulants that keep most patients awake - patients should not consume caffeine 6 hours before bedtime. You should have your last cigarette four hours or more before you sleep.

I still wonder how James Bond managed to smoke, have alcohol and still look refreshed.

There are a number of psychological causes for Insomnia :

Anxiety
Depression
Stress
Worry about sleep

SO WHAT SHOULD I DO IF I HAVE INSOMNIA?

Don't lie there - get out of bed and do something else - if you are not sleeping you should not be in your bedroom.
Keep a constant schedule: remember dont change your waking time no matter what time you go to bed
Exercise early - Do not exercise at night
Avoid napping if you an insomniac - remember daytime napping improves performance if you are not an insomniac
Sterilise the bedroom: the bedroom must be free of the TV, the Blackberry,the cell phone, the iPhone, Books, the alarm clock - the bedroom is only for sleep and sleeping with your partner.
Quit smoking
No alcohol
No tea, coffee and chocolate
Restrict your sleep: if you feel you only sleep 4 hours a night out of the eight hours you lie in bed than restrict your sleep to to the 4 hours that you need - this will improve your sleep efficiency. Use only the time you need to sleep.
Reduce environmental distractions.
Stop all over the counter supplements and medication for sleep unless prescribed - there is little evidence that using non-prescribed medication works - why waist your money and risk you health with these drugs or supplements - if they are proven not to work. If insomnia remains a problem than contact your health care provider that will direct the treatment at the underlying cause of the insomnia.

Medications of you must:

There are 3 classes of drugs that are approved for the treatment of Insomnia:

The Benzodiazepines - these work in an undirected manor on the brain - and may allow you to have sleepiness the next morning.
The non-benzodiazepines - The "Z" drugs - zolpidem and zaleplon. These act with the benzodiazepine receptor of the brain. Their advantage is the rapid absorption and lack of active metabolites, and low risk for side effects.
Melatonin - this has some interesting promise when used alone or in combination with the other approved sleep drugs. Melatonin is a naturally occurring hormone that is secreted by the pineal gland and controls the day night cycle in the brain - the circadian rhythm. Melatonin does not put you to sleep, but gets your night time hormones ready for sleep and in the event that you are asleep - makes your sleep more efficient. Please ensure that the melatonin that you buy is from a regulated pharmaceutical manufacturer - that apply the highest standards of quality or you may not be getting the melatonin you paid for as I have come to see with my SA patients.
Herbal remedies: Although there are very few studies proving the value of herbal treatments - Valerin and Keva are the most commonly promoted herbal remedies.

MOST EFFECTIVE TREATMENT

Prescription medication with behavioural treatments work best in combination. Cognative Behavioural therapy appears to be the most effective behavioural therapy. Sleep hygiene is imperative, limiting or controlling stimulus at bedtime.

Remember Insomnia is not a way of life - you need to seek appropriate medical help from your health care provider.

Dr Yacoob Omar Carrim

Sleep Medical Specialist

Zuid Afrikaans Hospital

zasleep@gmail.com

http://zasleep.blogspot.com

"Doctor I am getting fat but I am not eating"

2010-06-28T18:37:00.000+02:00

By Dr Carrim at Dec 7, 2009 3:12 PM IST
Obstructive Sleep Apnoea has a number of effects - amongst others sleep fragmentation and hypoxia. These effects initially stimulate leptin, Il6 and TNF from fat cells. Leptin resistance develops thereafter creating DIET RESISTANT FAT. This DIET RESISTANT FAT - is as the name suggest resistant to changes in diet.
Successful management with a CPAP would reduce the leptin resistance and allow the patient to loose weight.
Thanks
Dr Y Carrim
Sleep Specialist
South Africa
+27715216757

What Happens in the Brain When you sleep

2010-06-07T20:38:00.005+02:00

First we need to understand the DEEP STRUCTURES OF THE BRAIN

lentiform nucleus

The large, cone-shaped mass of gray matter that forms the central core of the cerebral hemisphere, whose convex base is formed by the putamen and whose apical part consists of the globus pallidus. Also called lenticular nucleus.

Caudate Nucleus
The caudate nucleus is a nucleus located within the basal ganglia of the brains of many animal species. The caudate nucleus is an important part of the brain's learning and memory system.

SUBSTANTIA NIGRA

Role of the Basal Ganglia

The basal ganglia play a complex and integral role in the control of movement:

Selecting and maintaining purposeful motor activity while suppressing unwanted or useless movement.
Helping monitor and coordinate slow, sustained contractions related to posture and support.
Inhibiting muscle tone throughout the body (proper muscle tone is normally maintained through a balance of excitatory and inihibtory inputs to the neurons that inervate skeletal muscle).

Compare the basal ganglia’s functions with thesymptoms of Parkinson’s disease.

Anatomy of the Basal Ganglia

src: Bear, M. F., Connors, B.W. & Paradiso M. A.,Neuroscience: Exploring the Brain, Second Edition, Lippincott Williams & Wilkins, 2001, pp 473-482.

The basal ganglia consists of thestriatum, the globus pallidus and thesubthalamic nucleus.
Thestriatum is the target of cortical input to the basal ganglia and can be divided into the caudate nucleus and the putamen.
The globus pallidus is the source of output to the thalamus and can be divided into an internal and external segment.
The substantia nigra is a midbrain structure that is reciprocally connected with the basal ganglia of the forebrain.

The Basal Ganglia and Movement

The command to initiate movement is implemented with the participation of subthalamic input to the SMA and PMC arising from the ventral lateral (VL) nucleus of the dorsal thalamus. The input to this part of the VL arises from the basal ganglia.
The basal ganglia, in turn, receive input from the cerebral cortex, particularly the frontal, prefrontal and parietal cortex. Hence information cycles from the cortex, to the basal ganglia and thalamus, and back to the cortex again, forming a loop that functions in the selection and initiation of willed movements.
Sources: Parkinson’s Disease site from Evergreen State College; Bear, M. F., Connors, B.W. & Paradiso M. A., Neuroscience: Exploring the Brain, Second Edition, 351 West Camden St., Baltimore, MD: Lippincott Williams & Wilkins, 2001, pp 473-482

The amygdalae (Latin, also corpus amygdaloideum, singular amygdala, from Greekαμυγδαλή, amygdalē, 'almond', 'tonsil', listed in theGray's Anatomy as the nucleus amygdalæ)^[1] are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans.^[2] Shown in research to perform a primary role in the processing andmemory of emotional reactions, the amygdalae are considered part of the limbic system.^[3].

The Cingulate Cortex:

The cingulate cortex is a part of the brainsituated in the medial aspect of the cortex. It includes the cortex of the cingulate gyrus, which lies immediately above the corpus callosum, and the continuation of this in the cingulate sulcus. The cingulate cortex is usually considered part of the limbic lobe, separate from the adjacentfrontal and parietal lobes.

It receives inputs from the thalamus and theneocortex, and projects to the entorhinal cortexvia the cingulum. It is an integral part of thelimbic system, which is involved with emotion formation and processing, learning, and memory, and is also important for executive function and respiratory control.

The Hippocampus

The hippocampus is a major component of the brains of humans and other mammals. It belongs to the limbic system and plays important roles in long-term memory and spatial navigation. Like the cerebral cortex, with which it is closely associated, it is a paired structure, with mirror-image halves in the left and right sides of the brain. In humans and other primates, the hippocampus is located inside the medial temporal lobe, beneath the cortical surface.

In Alzheimer's disease the hippocampus is one of the first regions of the brain to suffer damage; memory problems and disorientation appear among the first symptoms. Damage to the hippocampus can also result from oxygen starvation (hypoxia), encephalitis, or medial temporal lobe epilepsy. People with extensive hippocampal damage may experience amnesia—the inability to form or retain new memories.

In rodents, the hippocampus has been studied extensively as part of the brain system responsible for spatial memory and navigation. Many neurons in the rat and mouse hippocampus respond as place cells: that is, they fire bursts of action potentials when the animal passes through a specific part of its environment. Hippocampal place cells interact extensively with head direction cells, whose activity acts as an inertial compass, and with grid cells in the neighboring entorhinal cortex.

Since different neuronal cell types are neatly organized into layers in the hippocampus, it has frequently been used as a model system for studying neurophysiology. The form of neural plasticity known as long-term potentiation (LTP) was first discovered to occur in the hippocampus and has often been studied in this structure. LTP is widely believed to be one of the main neural mechanisms by which memory is stored in the brain.

Insomnia

2010-05-29T21:31:00.001+02:00

Having sufficient restful sleep is a critical human requirement. It is vital to emotional and physical well being. Most adults sleep between 6 and 8 hours per day, without interruption. A few nights of poor sleep do no harm, but prolonged sleep disturbances can have serious consequences.

The Physiology of Sleep

People function according to a natural cycle that repeats itself about every 24 hours. This is known as the circadian rhythm, and it governs our sleep-wake cycles. As it gets dark, the cells in the retina of the eye send a message directly to a part of the brain called the hypothalamus, which then signals the pineal gland located in the hypothalamus to produce the hormone melatonin, which causes a drop in body temperature and sleepiness. At the same time there is a reduction in the chemicals responsible for arousal, like histamine, noradrenalin, and serotonin. In a normal person, this sequence brings on sleep. There are two types of sleep: rapid eye movement (REM) and nonrapid eye movement (NREM). NREM has four stages, with stage 1 being transitional sleep, stage 2 light sleep and stages 3 and 4 deep (delta) sleep. Delta sleep is the most restful kind. During NREM sleep, brain activity and body functions slow. During REM there is increased activity - body functions speed up and a person dreams. A person moves from one phase of sleep to another during the night.

What is Insomnia?

Insomnia is a sleeping problem in which there is either inadequate sleeping time, or poor quality sleep, occurring on a regular or frequent basis, often for no apparent reason. A person with insomnia may have difficulty falling asleep, may wake up too early, wake up intermittently during the night, or may wake feeling unrefreshed.

During the day a person with insomnia may suffer from general tiredness, lack of energy, difficulty concentrating, and irritability. Sleep deprivation also impairs memory, reaction time and alertness. Tired people are less productive at work, less patient with others, and less interactive in relationships. Sleep deprivation can also be dangerous for people who have to drive. When people are deprived of sleep over long periods, the body's immune system becomes depressed, lowering resistance to disease and infections.

Insomnia is very common - between 20% and 30% of adults suffer insomnia to some degree, and about 10% to 15% of people have insomnia which is chronic or severe. Insomnia is more of a problem in the elderly, and is more common in women. Sleeping pills are amongst the most prescribed medicines in the world.

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Types of Insomnia

Transient insomnia is a temporary disturbance of the normal sleep pattern. It generally lasts no more than several nights, and usually disappears on returning to a regular sleep pattern. Travel or relocation may cause it.

Short-term insomnia lasts for 2 - 3 weeks and can accompany worry or stress. It often disappears if the cause is resolved.

Chronic insomnia disrupts sleep for extended periods of time - sleeping problems occur for at least 3 nights a week for one month or more. It is a complicated disorder with potentially serious effects.

What causes Insomnia?

Insomnia is usually the result of an underlying condition. Discovering the cause is the most important step in relieving insomnia.

Lifestyle factors are common causes of insomnia, particularly transient or short term insomnia. These include factors like high stress or anxiety, an uncomfortable sleeping environment, eating a heavy meal or drinking alcohol or caffeine-containing drinks before bedtime, exercising just before bedtime and cigarette smoking.

Medical conditions may cause chronic insomnia. These include chronic illnesses like kidney disease, heart failure or asthma, painful illnesses like arthritis or cancer, and hormone imbalances like hyperthyroidism, menopause or pregnancy.

Psychiatric conditions like depression, anxiety disorders or schizophrenia may be associated with chronic insomnia.

Medications are a common cause of insomnia. Some antidepressants, high blood pressure and steroid medications can interfere with sleep. Many painkillers, decongestants and weight loss products contain caffeine and other stimulants which will keep a person awake. Reducing or stopping your regular dose of sleeping pills may also cause insomnia.

Certain sleep disorders may result in insomnia. Restless leg syndrome is a condition where a person experiences unpleasant sensations in the legs or feet, preventing sleep. Periodic limb movement disorder is where uncontrollable twitching of the legs or arms prevent refreshing sleep. Obstructive sleep apnoea is a condition in which people intermittently stop breathing for short periods during sleep, causing them to wake frequently. Circadian rhythm disorders develop due to time zone changes (jet lag), or in people who do shift work.

Psycho Physiological Insomnia is one of the commonest causes of insomnia affecting about 5% of people. It develops when a person experiences a poor night's sleep and then has increased anxiety the next night, which again prevents him from falling asleep. This "vicious cycle" is repeated night after night, leading to chronic insomnia.

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How Is Insomnia Diagnosed?

The many potential causes of insomnia mentioned above can be determined by assessing lifestyle factors, by reviewing physical or psychiatric symptoms and by performing a physical examination. Certain laboratory tests and special investigations may be necessary. A sleep diary, which provides a record of how long and when you sleep, may also be helpful. In some patients an assessment at a sleep clinic may be necessary.

Treatment of Insomnia

Chronic or severe insomnia should be discussed with a doctor to rule out any medical or psychiatric condition.

Lifestyle changes: Regular moderate exercise, a balanced diet and avoiding excessive alcohol or caffeine will improve health and sleep. Reduce tension, promoting better sleep.

Behavioural therapies may also be used to treat some patients with insomnia. Relaxation therapy uses special techniques to calm the person and relax the muscles. Sleep restriction is a program that initially permits only a few hours of sleep per night, then gradually increases the nightly sleeping time. Reconditioning teaches the person to associate a bed with sleeping (and sexual activity), not daytime naps.

Drug treatment: If insomnia is transient or short-term, and sleep hygiene (see below) or non-medical treatments are not helpful, medication may be effective to prevent psycho physiological insomnia. In chronic insomnia, it is important to diagnose any underlying medical or psychiatric condition, and treat this effectively. Prolonged use of pills, without addressing the root cause may result in dependency. Hypnotic (sleep-inducing) medications, like the benzodiazepines, should be used for a few days at a time, to try to break a pattern of sleeplessness, while addressing any underlying problem. They should be used for short periods only, as they may become addictive. Antidepressants are effective in patients in whom depression has been diagnosed. Some Antihistamines have sedative effects and may be effective in the short-term. Melatonin may help insomnia by shifting the phases of the circadian rhythms, but is still undergoing further studies.

Sleep Hygiene is a holistic approach to sleeping. Good sleep hygiene prevents or relieves insomnia, and makes sleep more restful and pleasurable.

Establish a regular time for going to bed and waking up.
Use the bed for sleep or sexual activity only, not for reading, TV, or work.
Avoid naps, especially in the evening.
Exercise before dinner - exercising close to bedtime, however, may increase alertness.
Take a hot bath about an hour and a half before bedtime.
Do something relaxing in the half-hour before bed like reading or a walk.
Keep the bedroom cool and ventilated.
Do not look at the clock. Worrying about the time and "forcing" yourself to sleep makes it more difficult to sleep.
A light snack before bed can help sleep. A large meal may do the opposite.
Avoid fluids just before bedtime to reduce the need to urinate.
Avoid caffeine in the hours before sleep.
Quitting smoking eliminates the effects of nicotine on sleep loss.
People who can't sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until sleepy again.
If a person with insomnia is distracted by a sleeping bed partner, a couple of nights apart may be useful.

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Tips to beneficial sleep and feeling energized day after day: While many strategies are available, it is important to experiment and discover what works for you, what works for one person may not work for another!

Take control of the stressors in your life.
Focus on what's really important in life.
Make time for two or three quiet moments during the day and before retiring for the night.
Fitness through exercising.
Exercise will lower anxiety and tension.
Heart and lung fitness, a direct result of exercise, promote healthy sleep.
Easy stretching should precede all exercise.
Exercises such as walking, dancing and aerobic work outs should be done in the late afternoon.
Stay alert during the day.
Keep yourself busy and involved during your daytime activities.
Involvement with other people allows you to reduce stress by focusing on issues other than your own.
Eat balanced meals.
Make this part of the total, personal health plan.
Strive for a balance between vegetables, protein and carbohydrates.
Avoid a large meal within four hours of going to bed.
Alcohol and bedtime do not mix.
The effects of alcohol are greatly magnified by sleep deprivation.
Sleep apnoea can be aggravated by drinking at bedtime.
Avoid alcohol within three hours of bedtime.
Develop a bedtime ritual.
Read for pleasure.
Gradually dim the lights.
As your mind clears and you become drowsy, turn off the light.
Cleanse the mind.
Commit your worried thoughts to an index card on the night stand.
Add some points about the potential solution.
Leave the card there in case you awaken during the night.
Relaxation at bedtime
Play mind games with yourself.
Mental imagery.
Deep breathing.
Time in bed: Only as long as is necessary
You may go to bed earlier than usual due to stress and worries.
Stay in bed only for the period that you usually need for sleep.
Sleep until you are refreshed.
Consult a sleep specialist if needed.
Always share your sleep problems with your doctor.
He/she may give you valuable advice or refer you to a sleep specialist.
Awaking with shortness of breath or chest pain requires prompt attention.
Your doctor must be told if you are falling asleep at inappropriate times.

Reference: Maas J.B. (1999): Power Sleep, New York: Harper Perennial p84-99

Courtesy of Medical Essentials, Health Information

Internet-based Intervention May Improve Insomnia

2010-02-08T16:06:00.000+02:00

Internet-based Intervention May Improve Insomnia

4 Signs of Sleep Deprivation in Teens

2010-01-28T14:48:00.001+02:00

4 Signs of Sleep Deprivation in Teens

Signs of insufficient sleep may include the following:

Memory lapses and inattention
Irritability, depressed mood, being overly emotional
Falling asleep spontaneously during quiet times
Needing catch-up slee on the weekends

Obstructive sleep apnea (OSA), a form of sleep-disordered breathing

2010-01-28T14:11:00.000+02:00

OVERVIEW

Obstructive sleep apnea (OSA), a form of sleep-disordered breathing, encompasses a spectrum of breathing disturbances caused by narrowing of the upper airway. Zuid Afrikaans Sleep Centre treats a number of OSA patients each year and is a leader in research to better understand the disorder and develop new treatments.

Diagnosis

Dr Yacoob Omar Carrim's approach to diagnosis of OSA is based on advanced patient testing, examination and analysis of symptoms.

Treatment

Patients treated for OSA benefit from the combined expertise of top specialists working together across the fields of sleep medicine, otorhinolaryngology (ear, nose and throat), cardiology, orthodontics, oral surgery, endocrinology, and nursing. Each patient is unique and specialists combine their expertise to develop the best treatment plan possible.

Periodic Limb Movements during Sleep

2010-01-18T13:24:00.001+02:00

Periodic Limb Movements during Sleep

Periodic limb movement (PLM) disorder is unique in that the movements occur during sleep. Most other movement disorders manifest during wakefulness. The condition is remarkably periodic, and the movements may cause poor sleep and subsequent daytime somnolence. PLM disorder may occur with other sleep disorders and is related to, but not synonymous with, restless leg syndrome (RLS), a less specific condition with sensory features that manifest during wakefulness. The majority of patients with RLS have PLM disorder, but the reverse is not true. Treatment involves either dopaminergic medication in an attempt to modify activity of the subcortical motor system or, more commonly, sedative medications to allow uninterrupted sleep. Many new agents are proving efficacious for treatment as well.

Symonds first described PLM disorder in 1953. The original name, "nocturnal myoclonus," does not describe the condition accurately, since the movements are slower than are those of myoclonus. The original name seldom is used today.

The etiology of the primary form of PLM disorder is uncertain. Suprasegmental disinhibition of the descending inhibitory pathways may be a factor. Because the etiology is not clear, treatment is primarily symptomatic and does not modify the disease. Studies differ regarding the frequency of polyneuropathy in cases of PLM disorder. Martinez-Mena and Pastor found that only 1 of 9 patients had signs of neuropathy.

The secondary forms of PLM disorder may be due to diabetes mellitus, spinal cord tumor, sleep apnea syndrome, narcolepsy, uremia, or anemia. Many authors report an association between attention deficit hyperactivity disorder (ADHD) and PLM disorder. Antidopaminergic, dopaminergic, or tricyclic drug therapy or cessation of treatment with barbiturates or benzodiazepines may initiate the syndrome as well. Voderholzer and colleagues noted an increased incidence of periodic limb movements during sleep in patients with Gilles de la Tourette syndrome. However, the authors emphasized that the different responses to pharmacological treatments are evidence against a pathophysiological relationship between PLM disorder and Gilles de la Tourette syndrome.

The presenting symptom may be stereotyped periodic limb movements that cause awakening during the night, but often the presenting complaint is poor sleep and daytime somnolence. Haba-Rubio et al report that sleep changes induced by periodic limb movements during sleep (PLMS) are associated with decreased physical and psychological fitness on awakening.

Occasionally, a bed partner may provide the history of limb movements.
Nozawa and colleagues studied arousal index and movement index in PLM disorder and noted that the sleep-wake disorders associated with PLM relate to threshold of awakening.
Leg movements are stereotyped and involve one or both limbs.

The movement simulates triple flexion with leg flexion, ankle dorsiflexion, and great toe extension; it lasts approximately 2 seconds and thus is not consistent with the rapid jerk that defines true myoclonus.
The periodicity ranges from 20-40 seconds with a variable duration. The movements are said to occur mainly in non?rapid eye movement (REM) sleep.

Restless Legs Syndrome

2010-01-18T13:23:00.001+02:00

Restless Legs Syndrome

The term restless legs syndrome (RLS) was used initially in the mid-1940s by Swedish neurologist Karl A. Ekbom to describe a disorder characterized by sensory symptoms and motor disturbances of the limbs, mainly during rest. However, early descriptions date back to the 17th century. It is recognized now as a neurologic movement disorder of the limbs, often associated with a sleep complaint. Patients with RLS have a characteristic difficulty in trying to depict their symptoms; they may report sensations such as an almost irresistible urge to move the legs, which are not painful but are distinctly bothersome; this can lead to significant physical and emotional disability. The sensations usually are worse during inactivity and often interfere with sleep, leading to walking discomfort, chronic sleep deprivation, and stress. Once correctly diagnosed, RLS can usually be treated effectively by relieving symptoms; in some secondary cases, it can even be cured.

Pathogenesis of RLS is unclear. Ekbom originally proposed that it was mainly the result of accumulation of metabolites in the legs because of venous congestion. Peripheral nerve abnormalities also have been proposed, but no associated structural changes in nerve endings have been identified.

RLS also has been linked to dopaminergic or opiate abnormalities. Centrally acting dopamine receptor antagonists reactivate symptoms when given to patients with the syndrome. Results of single-photon emission computed tomography (SPECT) have suggested deficiency of dopamine D2 receptors. Sympathetic hyperactivity also has been implicated on the basis of observations that sympathetic nerve blockade relieves periodic limb movements of sleep and that alpha-adrenergic blockers improve symptoms of RLS. Studies also have suggested possible underactivity of the serotonin and gamma-aminobutyric acid (GABA) neurotransmitter systems.

The severity of symptoms in patients with RLS ranges from mild to intolerable. Although patients experience the sensations in their legs, they also may occur in the arms or elsewhere. RLS symptoms are generally worse in the evening and night and less severe in the morning. While RLS may present early in adult life with mild symptoms, usually by age 50 it progresses to daily severe disruption of sleep leading to decreased daytime alertness. RLS is associated with reduced quality of life in cross-sectional analysis.

A childhood-onset restless legs syndrome has also been described. A study published in Dec 2004 by Kotagal and Silber concluded that iron deficiency and a strong family history were characteristic of this childhood-onset presentation.

Insomnia

2010-01-18T13:22:00.001+02:00

Insomnia

Insomnia is the most common sleep complaint. It is a perception that sleep quality is inadequate or non-restorative, despite the adequate opportunity to sleep. That insomnia is a symptom, not a disease, is important to note; it is associated with a variety of medical, psychiatric, and sleep disorders. A comprehensive history and physical examination are essential to determine the etiology of the insomnia.

The complaint of insomnia encompasses many sleep problems. These include difficulty falling asleep, sleeping too lightly, being easily disrupted with multiple spontaneous awakenings, or early morning awakenings with inability to fall back asleep. The timing of insomnia is important in determining its etiology. Therefore, having each patient define what he or she means by insomnia is essential.

To be considered a disorder, the complaint of insomnia should be accompanied by distress and/or impairment in daytime functioning.

On the basis of duration, insomnia is commonly divided into the following 3 types:

Transient insomnia lasts up to 1 week and often is referred to as adjustment sleep disorder because it most often is caused by an acute situational stress, such as a new job, upcoming deadline, or exam. It often recurs with new or similar stresses.
Short-term insomnia lasts for 1-6 months and is usually associated with more persistent stressful situational (death or illness of a loved one) or environmental (noise) factors.
Chronic insomnia is any insomnia lasting more than 6 months and is associated with a wide variety of disorders.
Insomnia usually results from an interaction of biological, physical, psychological, and environmental factors.

Although transient insomnia can occur in any person, chronic insomnia appears to develop only in a subset of patients who may have predisposing factors. Evidence for this theory includes the following:

When compared to control subjects, individual with insomnia (1) have higher rates of depression and anxiety, (2) score higher on scales of arousal, (3) have longer daytime sleep latency, (4) have an increased 24-hour metabolic rate, (5) have more night-to-night variability in their sleep, and (6) may have more beta EEG activity (an EEG pattern seen during memory processing/performing tasks) at sleep onset.
In experimental models of insomnia, control subjects deprived of sleep do not demonstrate the same abnormalities in metabolism, daytime sleepiness, and personality as persons with insomnia.
In an experimental model of giving control subjects caffeine, causing a state of hyperarousal, the control subjects did have changes in metabolism, daytime sleepiness, and personality similar to those seen in individuals with insomnia.
These results support a theory that insomnia is a manifestation of hyperarousal. In other words, the poor sleep may not itself be the cause of the daytime dysfunction but merely the nocturnal manifestation of a general disorder of hyperarousability.

Therefore, chronic insomnia is believed to primarily occur in patients with predisposing factors. These factors may cause the occasional night of poor sleep, but in general, the patient sleeps well until the occurrence of a precipitating event, such as death or other life stress. Then, acute insomnia develops. If poor sleep habits or other perpetuating factors occur, chronic insomnia develops despite the removal of the precipitating factor.

As stated previously, insomnia is a symptom; an accurate differential diagnosis is essential for the proper management of this complaint in any given patient.

Transient and short-term insomnia: Etiologies can be divided into 2 broad categories, as follows:

Environmental - Unfamiliar or unconducive sleep environment due to factors such as too much noise or light, extremes of temperature, or poor bed
Stress - Primarily life events such as new job or school, deadlines or exams, or death of a relative or close friend
Chronic insomnia: Differential diagnosis is broader and includes the following categories:

Medical disorders - Include chronic pain syndromes from any cause (eg, arthritis, cancer), advanced COPD, chronic renal disease (especially if on hemodialysis), chronic fatigue syndrome, and fibromyalgia
Neurologic disorders - Include Parkinson disease and other movement disorders, as well as headache syndromes, particularly cluster headaches, which frequently are triggered by sleep
Psychiatric disorders - Most chronic psychiatric disorders
Depression most commonly is associated with early morning awakenings and inability to fall back asleep; studies also have shown that insomnia can lead to depression. (The presence of insomnia for longer than 1 year is associated with an increased risk of depression.)
Schizophrenia and the manic phase of bipolar illness frequently are associated with sleep-onset insomnia.
Anxiety disorders (including nocturnal panic disorder and posttraumatic stress disorder) are associated with both sleep-onset and sleep-maintenance complaints.
Drug-related insomnia: Sleep disruption is common with excessive use of stimulants, alcohol, or sedative-hypnotics.
Primary sleep disorders

Restless leg syndrome (RLS)/periodic limb movement disorder (PLMD) is a sleep disorder characterized by unpleasant physical sensations in the legs, often described as a motor restlessness; relief of symptoms through movement, with worsening in a recumbent position; and occurrence only in the evening, primarily at bedtime. It is frequently relieved by movement (in the case of RLS) and is usually (but not necessarily) associated with frequent and rhythmic leg kicking once asleep (in the case of PLMD). If RLS is predominant, sleep-onset insomnia is the rule; if PLMD is predominant, sleep-maintenance insomnia or daytime hypersomnolence is more likely.
In obstructive sleep apnea, a minority of patients complain of insomnia rather than hypersomnolence. They frequently complain of multiple awakenings or sleep-maintenance difficulties.
Circadian rhythm disorders, such as sleep phase advance (patient goes to bed early and rises early) and sleep phase delay (patient goes to bed late and rises late) syndromes can present as insomnia when the patient wants to either stay in bed later or go to bed earlier but cannot and then believes he or she has a problem sleeping. Shift workers also frequently have problems with insomnia, particularly when they want to sleep during the day.
Primary insomnia: If all the disorders already discussed have been ruled out, the patient has primary insomnia. Most primary insomnia is psychophysiologic insomnia; rarely, primary insomnia is caused by idiopathic insomnia (long-standing insomnia beginning in childhood without antecedent psychiatric or medical trauma) or sleep state misperception (insomnia with objective evidence of a sleep disorder).

Psychophysiologic insomnia is a disorder of somatized tension and learned sleep-preventing associations resulting in a complaint of insomnia and daytime fatigue.
Psychophysiologic insomnia begins with a prolonged period of stress in a person with previously adequate sleep. The patient responds to stress with somatized tension and agitation, causing physiologic arousal. The bedroom and/or sleep routine becomes associated with frustration and arousal; poor sleep hygiene follows.
In a normal sleeper, as the initial stress abates, the bad sleep habits are extinguished gradually, as they are not reinforced. However, in a sleeper with a tendency toward occasional poor sleep nights, bad habits are reinforced, the individual "learns" to worry about his or her sleep, and chronic insomnia follows.
History in these patients frequently reveals excessive daily worries about not being able to fall asleep, evidence of trying too hard to sleep with apprehension if unable to fall asleep, an ability to fall asleep during monotonous pursuits (such as watching TV or reading) and in inappropriate situations (at a lecture or while driving) but not when desired, improvement of sleep in unusual sleep environments, and increased agitation and muscle tension prior to bed.

Obstructive sleep apnea-hypopnea (OSAH)

2010-01-18T13:21:00.001+02:00

Obstructive Sleep Apnea

Obstructive sleep apnea-hypopnea (OSAH) is characterized by recurrent episodes of upper airway collapse and obstruction during sleep. These episodes of obstruction are associated with recurrent oxyhemoglobin desaturation and arousals from sleep. Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a term frequently used when this is associated with excessive daytime sleepiness. Despite being a common disease, OSAHS is unrecognized by most primary care physicians (an estimated 80% of OSAHS cases in the United States are not diagnosed).

The upper airway is a compliant tube and is therefore subject to collapse. The majority of patients with OSAHS demonstrate upper airway obstruction, either at the level of the soft palate (nasopharynx) or at the level of the tongue (oropharynx). Recent research indicates that both anatomic and neuromuscular factors are important. Anatomic factors, such as enlarged tonsils, macroglossia, or abnormal positioning of the maxilla and mandible, decrease the cross-sectional area of the upper airway and/or increase the pressure surrounding the airway, both of which predispose the airway to collapse.

Upper airway neuromuscular activity, including reflex activity, decreases with sleep, and this decrease may be more pronounced in patients with OSAHS. Reduced ventilatory motor output to upper airway muscles is believed to be the critical initiating event leading to upper airway obstruction; this effect is most pronounced in patients with an upper airway predisposed to collapse for anatomic reasons.

Central breathing instability has been well established to contribute to the development of central sleep apnea, particularly in patients with severe congestive heart failure (Leung, 2001; Xie, 2002; Xie, 1995). Some evidence indicates that central breathing instability also contributes to the development of OSAHS. First, evidence of upper airway obstruction in the absence of ventilatory motor output (central sleep apnea) has been observed (Badr, 1995). Second, reduction in pharyngeal dilator activity has been associated with periodic breathing (Hudgel, 1987; Warner, 1987; Onal, 1986) and hypocapnia in subjects with evidence of inspiratory flow limitation (IFL) (Badr, 1997). Third, men have been shown to be more susceptible to the development of central sleep apnea and have a decreased responsiveness to carbon dioxide than woman (Zhou, 2000); these findings are consistent with the increased prevalence of OSAHS in men.

Retrospective data indicate that mortality rate is higher in patients with an apnea-hypopnea index [AHI] greater than 20 per hour than in those with an AHI less than 20 per hour. Groups treated with tracheostomy or nasal continuous positive airway pressure (CPAP), however, had no premature deaths. Since nasal CPAP became the standard of treatment, the effect of OSAHS on mortality rates has not been re-examined in a large-scale study.

Systemic hypertension is observed in 50-70% of patients with OSAHS. Several large cross-sectional studies have demonstrated that OSAHS is a risk factor for developing hypertension independent of obesity, age, alcohol intake, and smoking (Hla, 1994; Nieto, 2000). More recently, people in the Wisconsin Cohort Study were prospectively monitored for the development of hypertension. The investigators found a dose-response relationship between the degree of OSAHS and the presence of hypertension 4 years later (odds ratio 2.03 for apnea-hypopnea index [AHI] 5-15 and 2.89 for AHI >15) independent of confounding variables. Several small studies have shown small reductions in blood pressure when nasal CPAP is used in the treatment of OSAHS, though whether it was systolic, diastolic, or mean pressure that was lowered varied by study. No definitive study has demonstrated that treating OSAHS with nasal CPAP lowers the blood pressure on a long-term basis.

Relationship to the metabolic syndrome: The metabolic syndrome is now recognized as an important contributor to the development of atherosclerosis and cardiovascular disease. As defined, a patient with the metabolic syndrome has increased fasting glucose levels, increased blood pressure, lipid abnormalities, and obesity. Evidence of pro-inflammatory and oxidative stress also exists in these patients. Growing evidence suggests that OSAHS may contribute to the metabolic derangements that characterize the metabolic syndrome.

Hypertension: The relationship between OSAHS and hypertension is outlined above.
Insulin resistance: Multiple studies have shown that patients with OSAHS have increased glucose levels and increased insulin resistance (Ip, 2002; Punjabi, 2002; Punjabi, 2004). The most recent study was from the Sleep Heart Health Study (Punjabi, 2004). In this study of 2000 research subjects, the prevalence of diabetic 2-hour glucose tolerance values rose from 9.3% in the group with an AHI less than 5 to 15% in the group with an AHI greater than 15. The odds ratio for having an abnormal glucose tolerance test was 1.44 (p<0.0001) for the group with an AHI greater than 15; insulin resistance was also highest in this group. Correlations were also noted for the degree of oxygen desaturation at night, indicating that the OSAHS may contribute to insulin resistance as a result of the hypoxemia that occurs with the syndrome.
Oxidative stress: OSAHS has been associated with increased production of reactive oxygen species (Dyugovskaya, 2002) and other oxidative stress biomarkers (Lavie, 2004).
Vasodilator responses: OSAHS has been associated with decreased production of nitric oxide (Ip, 2000). Several studies have shown impaired vasodilator responses, as measured by either flow-mediated dilatation (Ip, 2004) or reactive hyperemic blood flow (Imadojemu, 2002) techniques. Impaired flow-mediated dilatation was found to best correlated with the degree of oxygen desaturation in an epidemiologic cohort study (Nieto, 2004).
Note that for most of these abnormalities, evidence from studies with small numbers of subjects suggests that CPAP partially reverses the metabolic abnormality that is the focus of the study (ie, CPAP decreased insulin resistance, decreased lipid peroxidation, increased vasodilator responses).
A large epidemiologic study (the Sleep Heart Health Study) is presently being conducted to provide more definitive data regarding the relationship between sleep apnea and cardiovascular morbidity. Initial findings from the SHHS indicate that a relationship exists between severe OSAHS and an increased risk of coronary artery disease, congestive heart failure, and stroke (Shahar, 2001). This study is ongoing to determine if the presence of OSAHS is associated with the development of cardiovascular morbidity.

A recent study found that OSAHS was associated with an increased risk of sudden death between the hours of midnight and 6 am, as compared to the general population (sudden death more common between 6 am and noon) (Gami, 2005).

Recent evidence indicates that OSAHS is not an independent risk factor for the development of pulmonary hypertension in the absence of other lung disease, as evidenced by the presence of daytime hypoxemia, hypercapnia, or obstructive airways disease.